Special Report: Who Lives, Who Dies, Who Tells Your Story? The Magic of Narrative Medicine in the ED

Shaw, Gina

doi: 10.1097/01.EEM.0000511938.81391.17
Special Report

A certain New York Times essay probably popped up in your Twitter or Facebook feed multiple times over the past couple of months, or it's been texted to you a few dozen times by colleagues and friends. There's a reason for that: It's an intensely powerful piece of writing.

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In “How to Tell a Mother Her Child Is Dead,” Temple University emergency physician Naomi Rosenberg, MD, almost literally grabs you by the lapels of your white coat with her very first sentences: “First you get your coat. I don't care if you don't remember where you left it, you find it. If there was a lot of blood you ask someone to go quickly to the basement to get you a new set of scrubs. You put on your coat and you go into the bathroom. You look in the mirror and you say it. You use the mother's name and you use her child's name. You may not adjust this part in any way.” (Sept. 3, 2016; http://nyti.ms/2fZFEHy.)

Dr. Rosenberg wrote the essay in July during a weeklong program in nonfiction writing at the Iowa Writer's Workshop. The prompt: “Write instructions on how to do something that you know how to do.” But the idea for it had first begun germinating when she attended a weekend seminar in narrative medicine last fall at Columbia University School of Medicine. (http://bit.ly/ColumbiaNarrative.)

“I wasn't writing it to be published,” Dr. Rosenberg said. “I was writing it for me.” But she showed the essay to Michael Vitez, a Pulitzer Prize-winning journalist from the Philadelphia Inquirer who recently joined the Temple faculty as the founding director of its new program in narrative medicine, and he suggested that she send it to the Times. It was accepted almost immediately.

The essay immediately went viral when it was published. Dr. Rosenberg heard from hundreds of people who had been touched by the piece. “I heard from mothers who said, ‘Thank you for helping me understand what happened that day,’” she said. “That was really meaningful.”

She heard from many doctors as well. “A lot of them told me that they'd never had training on how to tell someone that their child or wife or father is dead. Older doctors said that they had laughed nervously or stuttered or said exactly what they didn't mean to say, and were still thinking about it 50 years later. One person said, ‘The first time I went in to tell someone about the death of a patient was the first time I'd ever said those words out loud.’” (Dr. Rosenberg's essay advises doctors to practice the words in front of a mirror. “If it takes you fewer than five tries you are rushing it and you will not do it right.”)

Despite the ongoing reverberations of Dr. Rosenberg's essay because of its publication in probably the most famous newspaper in the world, it would have been just as important that she had written it even if she never shared it with anyone or only with people she knew, said Rita Charon, MD, the founder of the pioneering narrative medicine program at Columbia.

Narrative medicine doesn't simply teach doctors how to write, she said; it teaches them to be better doctors by learning to listen and understand their patients, their colleagues, and themselves. “With creativity comes discovery,” Dr. Charon said. “Narrative medicine is a deep kind of training in not just how to write, but also how to hear, how to listen, and how to receive what the patient is telling you so that you comprehend it more fully.”

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With Creativity Comes Discovery

Columbia's program in narrative medicine, the first of its kind in the nation and still just about the only one of its scope, began in the 1990s, although at the time it was called humanities in medicine. The name “narrative medicine” was adopted in 2000.

All first-year medical students at Columbia are now required to choose from about a dozen half-semester seminars, ranging from narrative writing to the history of medicine, ethics, visual arts, religious studies, and alternative medicine. They may go to the Frick Museum to explore the relationship between art and medicine, experience the Dance for Parkinson's Disease class at the Mark Morris Dance Center in Brooklyn, or participate in an obituary writing workshop to tell the life stories of anatomic donors.

“We teach people how to read, how to listen, how to write their own stories, and see what happens when someone else listens to them,” Dr. Charon said. “A lot of it is more based in the listening than in the writing. We work on listening purely without a hypothesis, not listening just in order to prove your point. As the Buddhists put it, we listen with a beginner's mind. It's very hard for doctors to tolerate doubt and uncertainty. But this is teachable.”

Students are required to establish a portfolio of their writings, a kind of electronic journal, which is reviewed by trained preceptors. They're asked to go back and read what they've written every semester, which teaches them a lot about themselves.”

Fourth-year students can also choose an intensive, month-long elective in narrative medicine, in which, the program brochure says, “Close reading, writing fiction, and reflective writing develop narrative and literary skills that end up adding to one's clinical effectiveness.” Or as Dr. Charon puts it: “It gives them the leeway to continue to discover parts of themselves in the creative realm.” One student, for example, conducted extensive interviews with a group of Haitian women who were migrant farmers in the Dominican Republic, and wrote about their health needs.

Outside the medical school curriculum, Columbia also offers weekend seminars like the one in which Dr. Rosenberg participated and a master of science in narrative medicine degree that can be obtained by clinicians and non-clinicians alike.

With Temple's narrative medicine program, Mr. Vitez said he is trying to create a culture of stories and storytelling. “I believe that stories have the power to heal, to inspire, to bring people together,” he said.

He launched the program with two new humanities electives being added to the curriculum. One is a seven-week elective exploration of narrative medicine. “We're having the students do things like shadow the palliative care team and write about their experience or go with the internal medicine residents to help them interview patients and take a history, then tell a story about the patient,” Mr. Vitez said. (http://bit.ly/TempleNarrative.)

The other elective, “Humans of North Philly,” is Temple's version of the popular “Humans of New York” blog and book. “I got a photographer friend to go with us into the neighborhood around the hospital and medical school to meet people, get to know them, take their pictures, and tell their stories,” he said. “We're going to put up a gallery in the medical school. It's about building a bridge between the medical school and the community we serve.”

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Narrative Medicine at 90 MPH

The very idea of narrative medicine sounds almost leisurely. How can such an approach help emergency physicians and inform their care of patients they don't know? Do they have time to sit and listen to someone's story in the hectic ED?

Absolutely, said Dr. Charon. “In emergency medicine, you often see these dramatic, consequential things happening so quickly. An elderly woman dies. You have to bump this patient out of the ICU. You wanted to admit this ED patient, but she left,” she said. “You're driven and dogged and always behind, and it's the narrative skill of writing, of listening more skillfully to what your patients say, what your colleagues say, and your own internal monologue that allows you to recognize the tragic magnitude of what goes on all the time in front of your eyes.”

Indeed, such skills can be even more important for an emergency physician than for a family physician or an internist who might have more time to process their patients' stories. “In the ED, a complete stranger comes in bleeding to death or having a big heart attack or a stroke so bad she can't speak,” Dr. Charon said. “You often don't have to go through the entire drill of asking every question in the book. It saves time for a skilled physician to be able to take in all the clues from what the patient and family and everyone else is saying and grasp the reality. You have to have the extraordinary skill to quickly tune in, to grasp the little clues you get, not just about where the stroke is in this person's brain, but who is this person who has had this stroke.”

She said she need look no further for an illustration of the importance of these skills to emergency medicine than her own ED, where a longtime student of hers with a doctorate in English is on the attending staff. “He's a very skilled writer-scholar, and it's made a big difference in his practice of emergency medicine because he is a very good listener, reader, and ‘understander’ of stories. He's able to let the patient lead him to the heart of the matter very quickly before he even reads the chart.”

A day that includes a visit to the emergency department is, with few exceptions, a day in someone's life that they will never forget, Dr. Rosenberg said. “By definition, we're present when something extraordinary is happening in this person's life. Narrative medicine asks all of us to remember that every patient is more than a series of diagnoses or lab results, and in the ED, that is especially essential. It's so fast-paced that by sheer volume, we don't have time to stop for an hour in a shift to reflect. We leave and have been part of things that are hard to leave behind. Narrative medicine helps us to take all that and make sense of it.”

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